This document provides a brief primer on the complex relationship between substance abuse and mental illness. It discusses several categories of commonly abused substances, including alcohol/cross-tolerant drugs, cannabinoids, stimulants, hallucinogens, opioids, inhalants, and others. For each category, it outlines the typical signs and symptoms of intoxication and withdrawal, and how substance use can cause, compound, or mimic mental health conditions like depression, anxiety, mania, and psychosis. The document aims to help readers understand how substances are grouped based on their similar effects, and recognize substance-induced versus underlying mental illness.

1. Drugs? Mental Illness?
Both?:
A brief primer on a complicated topic
Brian Stroh, MD
Assistant Medical Director
Netcare Corporation

2. Objectives
 The learner will:
 Learn similarities and differences among
different substances of abuse
 Be able to identify how those under the
influence of or in withdrawal from a substance
might appear
 Gain an understanding of how substances of
abuse can cause, compound, and/or mimic the
signs and symptoms of mental illness
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3. General Principles
 One of the easiest ways to learn about
substances of abuse is to consider
drugs that have similar effects in the
user.
 Learning about groups of substances,
rather than substances individually,
enables one to quickly learn
similarities and differences in a
manner that’s likely more applicable in
the field.
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4. General Principles
 For our purposes, we’ll be looking at
groups as follows:
 Alcohol and cross-tolerant drugs
 Cannabinoids
 Stimulants
 Hallucinogens
 Opioids
 Inhalants
 “Other”
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5. Alcohol and Cross-Tolerant
Drugs
 Cross tolerance: “tolerance or
resistance to a drug that develops
through continued use of another drug
with similar pharmacological action”
 Put another way, cross tolerance is
the situation in which different
substances act the same way in the
body – including the brain.
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6. Alcohol and Cross-Tolerant
Drugs
 The body sees alcohol as essentially
identical to benzodiazepines and
barbiturates – as regards intoxication,
withdrawal, and how all of these
compound the effects of mental
illness.
 Common benzos and barbs include:
 Benzos: Xanax (alprazolam), Ativan
(lorazepam), Klonopin (clonazepam), Valium
(diazepam), Ambien (zolpidem)
 Barbs: Fioricet/Fiorinal (contain butalbital),
phenobarbital, secobarbital
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7. Alcohol and Cross-Tolerant
Drugs
 Pertinent signs/symptoms of intoxication:
whether alcohol, benzos, or barbs, the
person in question appears drunk.
 Pertinent signs/symptoms of withdrawal
(i.e., signs/symptoms present in the
absence of a substance, when
substance has been used chronically):
sweating, shaking, hallucinations,
disorientation, and seizures.
Alcohol/benzo/barb withdrawal is life-
threatening. 7

8. Alcohol and Cross-Tolerant
Drugs
 Alcohol, benzos, and barbs all have the
potential to CAUSE depression, mania,
anxiety, and psychosis.
 Unfortunately, all of these substances
also have the potential to WORSEN
preexisting or underlying mental health
problems.
 “Self-medicating” may offer short-term
relief from a given emotional state, but
almost invariably compounds the
underlying problem if there is one.
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9. Questions So Far?
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10. Cannabinoids
 For years, the only widely available
cannabinoid compounds were
marijuana, hashish, and prescription
Marinol (dronabinol).
 Within the past several years,
“synthetic cannabinoids” such as K2
and Spice have appeared on the
streets:
 Not detected in drug screens
 “Not illegal, so they must be legal”
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11. Cannabinoids
 Intoxication with marijuana, hashish,
and Marinol all appear similarly:
 Common: euphoria/”giddiness,” sense of
calmness, lethargy/sedation, impairments of
motor skills/cognition, disturbance in sense of
time passing.
 Less common: Sadness, anxiety, social
withdrawal, psychosis
 There is some thought that K2, Spice,
and similar “synthetics” may cause
more serious effects than those of
older compounds.
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12. Cannabinoids
 Only with the advent of DSM-5 was
withdrawal formally defined to include
any combination of irritability,
depression, sleeplessness, decreased
appetite, anxiety, and drug craving.
 Note that intoxication symptoms and
withdrawal symptoms are rough
opposites.
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13. Cannabinoids
 As you might surmise from the above,
both intoxication and withdrawal can
both cause and mimic:
 Depression
 Anxiety
 Mania/Irritability
 Psychosis
 Cognitive impairment
 All cannabinoids also frequently
exacerbate underlying disorders.
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14. Stimulants
 Stimulants include, but aren’t
necessarily limited to:
 Cocaine (powdered, crack)
 Street-produced methamphetamine
 Prescription meds: Desoxyn
(methamphetamine), Ritalin/Concerta
(methylphenidate), Adderall (“amphetamine
mixed salts” or
amphetamine/dextroamphetamine), Focalin
(dexmethylphenidate)
 Khat
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15. Stimulants
 Intoxication involves:
 Common: mood changes (typically euphoria,
irritability, or anger), talkativeness/gregariousness,
hyperactivity/restlessness, increased alertness,
repetitive behaviors, impaired judgment, decreased
appetite and need for sleep, increased heart rate
and blood pressure
 Less common: Psychosis, anxiety, social
withdrawal
 Withdrawal involves (again, opposites):
 Depression, increased appetite and need for sleep,
lack of interest in pleasurable things
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16. Stimulants
 Not difficult to see that such a varied
set of symptoms as occurs across the
spectrum of intoxication to withdrawal
and back again could mimic mental
illness, especially bipolar disorder.
 Stimulants are potent causes of
substance-induced symptoms without
underlying illness, and similarly
significantly exacerbate primary
mental health concerns.
16

17. Meth: It’s Back!
 Live PD: Talking Nonsense
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18. Questions about Cannabinoids
or Stimulants?
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19. Hallucinogens
 Hallucinogens, as a group, are defined
by their primary effect of inducing
hallucinations.
 As we’ve seen before, however, plenty
of other substances can cause
psychosis, and hallucinations are a
psychotic symptom.
 Hallucinogens proper, as primary
substances of abuse, are much less
abused today than in decades past.
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20. Hallucinogens
 Common hallucinogens include PCP
(“angel dust”), LSD (“acid”), and
peyote (mescaline).
 Hallucinogens now most commonly
used to cut other drugs.
 Whereas the hallucinations inherent in
primary mental illness are most
frequently auditory, visual and tactile
hallucinations are much more
commonly attributed to drugs/alcohol.
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21. Hallucinogens
 Incredible agitation, florid psychosis, and
almost superhuman strength in
combination are suggestive of PCP
intoxication.
 Synesthesia (the mixing or blurring of
senses; “I can taste colors,” etc.) is also
strongly suggestive of hallucinogen use.
 “Flashbacks” as if intoxicated on
hallucinogens can occur years after last
use.
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22. Opioids
 As you are no doubt aware, opioids
are the fastest-growing substance
abuse problem in the US currently.
 About 20 years ago, there was a
strong push in medicine to treat pain
aggressively. Opioids, which had
previously been prescribed relatively
sparingly, have since skyrocketed in
both frequency and quantity
prescribed.
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23. Opioids
 As patients became addicted to
physician-prescribed substances, they
were often either not able to obtain the
increasing quantity of substances
needed to feed the addiction, or were
cut off entirely by rightfully suspicious
prescribers.
 That subset of patients (i.e., those cut
off and not wanting to stop) is left with
either prescription opioids from the
streets, or heroin.
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24. How Does Opioid Addiction
Occur?
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25. Opioids
 Common prescription opioids (listed in
order of increasing potency) include:
 Codeine (Tylenol #3/#4; various Rx cough
syrups)
 Hydrocodone (opioid ingredient in Lortab,
Norco, Vicodin)
 Oxycodone (opioid ingredient in Percocet; also
OxyContin)
 Meperidine (Demerol)
 Morphine (MS-Contin)
 Methadone
 Hydromorphone (Dilaudid)
 Fentanyl (Duragesic patches; Actiq lollipops)
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26. Opioids
 Intoxication includes any mix of:
 Common: Euphoria and/or apathy, sedation,
slurred speech, memory impairment,
constricted pupils, constipation (with chronic
use)
 Less common: Psychosis, disorientation
 Withdrawal (largely opposites)
includes any mix of:
 Insomnia (yet with yawning), sadness/anxiety/
irritability, body aches, diarrhea,
nausea/vomiting, dilated pupils, runny nose,
piloerection (“gooseflesh”)
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27. Opioids
 Opioids produce a wide array of mood
and anxiety symptoms and can
exacerbate underlying mental illness.
 Psychosis, whether as related to
intoxication or withdrawal, is less likely
to be caused by opioids, though
opioids are well-known to exacerbate
underlying psychosis.
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28. Questions about Hallucinogens
or Opioids?
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29. Inhalants
 The vapors of numerous widely
available household chemicals can be
inhaled to produce a high. These
include, but aren’t limited to:
 Gasoline/kerosene/diesel fuel
 Glue and other adhesives
 Paint and paint thinner
 Propellants in aerosol cans
 Cleaning solutions meant for electronic devices
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30. Inhalants
 As these substances are widely
available and generally not monitored
the same way that alcohol and
household drugs often are, it’s likely
not surprising that inhalant use is
disproportionately prevalent in youth.
 Still, not overly common in US society
today.
 Interestingly, no real withdrawal
symptoms.
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31. Inhalants
 Intoxication generally presents as:
 Common: Confusion, euphoria and/or
belligerence/assaultiveness, impaired
judgment, dizziness, blurred and/or double
vision, lack of coordination, slurred speech
 Less common (higher doses): Lethargy,
decreased motor movements, muscle
weakness, decreased reflexes, coma.
 Again, readily mimics mood disorders
and exacerbates underlying problems.
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32. “Others”
 There are always new and different
substances being put forth by
“chemists” looking to make a market.
 Substances today that aren’t as neatly
fitted to one of the categories we’ve
discussed today include:
 Ecstacy (aka MDMA)
 “Molly”
 Bath salts (multiple substances)
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33. “Others”
 Ecstacy is technically classified as a
stimulant (the A in MDMA is for
“amphetamine”), though produces
somewhat different effects in the user:
 Heightened sensory awareness (color, texture,
taste, smell)
 Sense of connectedness (this is “the love
drug”)
 Teeth grinding (pacifiers, suckers, etc. used to
combat)
 Likely to cause dehydration and hyperthermia,
making this drug exceedingly dangerous
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34. “Others”
 Users are often profoundly depressed
(the “suicide Monday” phenomenon)
when they stop using and may be
excessively sleepy.
 “Molly,” which is most often purported
to be “pure Ecstacy,” actually most
often contains any of a number of
drugs which largely mimic the effects
of MDMA but are less predictable as
they do so.
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35. “Others”
 Bath salts, not unlike PCP before
them, have taken on something of a
deservedly bad rap, and use as noted
by clinicians has plummeted.
 The “not illegal, so they must be legal”
logic, coupled with what was initially
plainly visible retail distribution, led to
a huge surge of intoxicated individuals
who were very difficult to treat.
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36. “Others”
 Like PCP and unlike many other
substances of abuse, bath salt users are
much more likely to have symptoms that
do not respond to medications, even at
high doses.
 Intoxication often includes: paranoia and
other delusions, hallucinations, violent
behavior, suicidal thoughts, panic
attacks, seizures, increased blood
pressure and heart rate, chest pain,
nausea and vomiting
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37. Questions about Inhalants and
“Others?”
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38. Summary
 Drugs and alcohol can mimic the signs
and symptoms of mental illness, and
in many cases directly cause them.
 Some people use drugs and alcohol
as a means to alleviate their problems
with mood, anxiety, or psychosis – but,
unfortunately, almost always end up
exacerbating the underlying problem.
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39. Summary
 Those with substance-induced
psychiatric symptoms are best treated
in drug and alcohol treatment
programs.
 Those with “dual diagnosis” (mixed
AOD and psychiatric problems) need
concurrent treatment for both
problems; treatment for one alone is
most often minimally effective, if at all.
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40. Final Questions, Comments, or
Concerns?
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